For the Complainant - Mr. Sujoy Kumar Basu, Advocate
For the OP -Mr. AK. Bandopadhyay, Advocate
FINAL ORDER/JUDGEMENT
SHRI SWAPAN KUMAR MAHANTY, PRESIDENT
Brief facts of Consumer Complaint :
Complainant filed the instant consumer complaint under section 12 of the Consumer Protection Act, 1986 pleaded therein that he himself and his wife Smt Lina Banerjee obtained Parivas Medi-claim Plus (Floater) Policy being No. 101800/48/16/8500005630 from OP National Insurance Company Limited. First Policy was issued in 2000 and thereafter renewed every year from 03.09.2017 to 02.09.2018. Coverage of policy was Rs.10,00,000/-.It is pleaded that on 23.12.2016 Smt. Lina Banerjee was admitted to Microlap Nursing Home with Acute Renal Failure / Acute Kidney Infection and discharged on 27.12.2016. Smt. Banerjee was admitted to Amri Hospital, Dhakuria on 02.01.2017 and discharged on 07.01.2017 and 21.02.2017 respectively with Hypertension and Dyslipidemia. She had further admitted to same hospital on 28.05.2017 with Urosepsis and discharged on 05.06.2017. Complainant had lodged claim of Rs.10,00,000/- to the OP for reimbursement and also submitted all related bills along with claim. OP/Insurer had settled the claim of Rs.6, 50,116/- out of total claim and arbitrarily withhold balance claim amount of Rs. 3,49,884/-. Spite several correspondences the O.P did not reimburse balance legitimate claim and ultimately repudiated the claim vide letter dated 16.07.2018. The OP committed deficiency in service. Hence, the prayer for acceptance of consumer complaint sought.
Per-contra OP National Insurance Company Ltd. filed written version pleaded therein that complainant and his wife Smt. Lina Banerjee was policy holder of National Mediclaim Policy being No.101800/48/15/8500005325 with sum insured of Rs.5,00,000/- and cumulative bonus of Rs.1,42,500/-. It is further pleaded that policy amount was enhanced to Rs.10,00,000/- under National Parivar Mediclaim Plus (Floater) Policy being No.101800/48/16/8500005630 for the period from 03.09.2016 to 02.09.2017. Smt. Banerjee was admitted in Amri Hospital, Dhakuria on 02.01.2017 with Post Infection Irritable Bowel Syndrome, Hypertension, Hyperlipidemia and discharge on 07.01.2017. Insured Smt. Banerjee was again admitted in Amri Hospital, Dhakuria on 09.01.2017 for the treatment of Crohn’s disease, Hypertension and Dyslipidemia and discharged on 21.022017. Smt. Banerjee further admitted in same hospital with same treatment on28.05.2017. Insured Smt. Banerjee has been suffering from Hypertension since November, 2009 though the policy inception date is 03.09.2016. Disease of patient is pre-existing in nature for which sum insured was restricted to Rs.5,00,000/-.Complainant had also lodged other claims in the year 2016 to 2017 under the policy No. 101800/48/16/8500005630 and the Insurer sanctioned Rs.6,43,444/- out of total claim after adding cumulative bonus of Rs.1,42,500/- with insured amount of Rs.5,00,000/- claims vide Nos.1486743, 1407293 and 1406336 were rejected on account of exhaustion of sum insured of Smt.Lina Banerjee. Thus, the OP is not under obligation to pay the balance amount of insurance claim . Prayer for dismissal of consumer complaint sought.
Decision with Reasons
Complainant and authorized signatory of OP led evidence through affidavit. They have also filed questionnaire and replies vis-à-vis relevant documents in support of their respective cases.
Short question for adjudication in this complaint is whether the claim of the complainant in the facts and circumstances of the case is payable. This leads to another question whether the claim is covered within the parameters of the policy or there exists any encumbrances. We have gone through the evidence as well as documents on record and given a thoughtful consideration to the subject matter.
There is no disputing the fact that the complainant and his wife Smt. Lina Banerjee was a policy holder of National Mediclaim Policy being NO. 101800/48/15/8500005325 for the period 03.09.2015 to 02.09.2016 with sum insured of Rs. 5,00,000/-. Cumulative bones of Rs. 1,42,500/- added with insured amount. It is also not disputed that insured amount was enhanced to Rs. 10,00,000/- under National Parivar Mediclaim Plus (Floater) Policy being No. 101800/48/16/8500005630 for the period 03.09.2016 to 02.09.2017.
On perusal of the discharge summary dated 27.12.2016 of insured Smt. Lina Banerjee would show that she was admitted in Microlap Nursing Home, Kolkata-700026 on 23.12.2016 for the treatment of Acute Renal Failure/Acute Kidney Infection. Complainant submitted claim of Rs. 43,890/- (Claim ID No. 1407242 dated 06.03.2017) for reimbursement which he incurred for treatment of his wife OP sanctioned Rs. 37,324/-.
Discharge Diagnosis dated 07.01.2017 show that insured Smt. Lina Banerjee was admitted in Amri Hospitals Ltd., Gariahat Kolkata on 02.01.2017 for the treatment of Probable Post Infection Irritable Syndrome, Dyselectrolytemia, Hypertension and Hyperlipidemia. The reimbursement which the complainant sought from the insurer was Rs. 54,696/- (claim ID No. 1407336 dated 06.03.2017) which he incurred and the OP/Insurer sanctioned Rs. 47,678/-. Insured Smt. Lina Banerjee again admitted in Amri Hospitals Ltd. on 09.01.2017 for the treatment of Crohn’s Disease (Affecting Jejunum), Hypertension and Dyslipidemia. She was discharged on 21.02.2017. Complainant sought reimbursement of Rs. 7,47,368/- vide claim ID No. 1407293 dated 06.03.2017 from the OP/Insurer for treatment of his wife. OP/Insurer sanctioned Rs. 4,14,939/- and disallowed Rs. 3,14,025/-.
No doubt that the Insured Smt. Lina Banerjee further admitted in the said hospital on 28.05.2017 for the treatment of Urosepsis (Klebsiella), GTCS (Seizure Disorder), Chrohn’s Disease, Hypertension and Dyslipidemia. Patient was discharged on 05.06.2017. Complainant submitted claim being ID Nos. 1542273 and 1599416 both dated 27.06.2017 for Rs. 1,43,423 and Rs. 16,454/- respectively to the OP. OP/Insurer repudiated the claim vide letter dated 16.07.2018 on the ground of that “the member has exhausted sum insured limit with previous claims and does not have any balance claim. ”. Complainant had lodged claim in the year 2016 to 2017 under the subject policy being No. 101800/48/16/8500005630 and insured amount was enhanced to Rs. 10,00,000/- under the subject Floater policy for the period 03.09.2016 to 02.09.2017. During the period 03.09.2016 to 02.09.2017 insured Smt. Lina Banerjee was admitted in Nursing Home and Hospitals in four times. Her total claim amount was Rs. 10,00,000/- and the OP/Insurer had settled the claim at Rs. 6,50,116/- out of Rs. 10,00,000/-.
Grievance of the complainant is that the OP unlawfully and arbitrarily did not disburse the balance claim amount of Rs. 3,49,884/- which tantamount to deficiency in service. No doubt the claim of the complainant is covered under the subject policy for the period 03.09.2016 to 02.09.2017 having assured sum of Rs. 10,00,000/- as floater.
The reimbursement which the complainant sought from the OP/insurer was for the expenses which he incurred for the medical treatment of his wife under the subject floater policy. As per the discharge diagnosis dated 07.01.2017 there is an old case of hypertension. The said discharge diagnosis does not show how old probable post infection irritable Bowel Syndrome, Dyselectrolytemia- subsequently corrected and Hyperlipidemia were. Though, there is evidence to prove that the insured Smt. Lina Banerjee was suffering from hypertension 15 years before taking the policy, the reimbursement of complainant sought is not only for treatment of hypertension but is for Acute Renal Failure/ Acute Kidney Infection, probable post infection irritable bowel syndrome, Dyselectrolytemia- subsequently corrected, hyperlipidemia and crohn’s disease which were done in Microlap Nursing Home and Amri Hospitals Ltd. , Dhakuria. No evidence is forthcoming on the part of the OP to prove that patient was suffering other ailments fully mentioned in the discharge diagnosis at the time of the policy was initially taken in the year 2000. No doubt hypertension may be one or more causes of someone developing other ailments fully mentioned in the discharge diagnosis of Microlap Nursing Home and Amri Hospitals Ltd. but it is not necessary that even a controlled hypertension would lead to the patient to Acute Renal Failure/Acute Kidney Infection, probably post infection irritable bowel syndrome and dyslipidemia. Therefore, we are unable to accept the contention that the disease of the insurer is covered under clause No. 4 read with 4.1 and 4.3 of the subject policy terms & conditions. It is true that hypertension has been concealed by the complainant and his wife while obtaining the insurance policy, he/she having replied in negative when asked whether she was suffering from hypertension. But, on perusal of the repudiating letter dated 16.07.2018 would show that the aforesaid concealment is not a ground for repudiation of the claim.
The Hon’ble Supreme Court in Galada Power and Telecomunication Ltd. vs. United India Insurance Company Ltd. and Another. Reported iv 2016 CPJ 5 SC has been pleased to held that the insurer cannot be allowed to travel beyond the ground taken in the repudiation letter issued by it while rejecting the claim. Therefore, the aforesaid concealment cannot be a ground for dismissing the complaint, the same not being one of the grounds for repudiating the claim. In our opinion, there is deficiency in service on the part of the OP for rejecting the claim of the complainant. Thus, the complainant is entitled to get relief as prayed for. Hence, we answer only point accordingly.
In view of the above discussions, the complaint is allowed on contest with the following directing:
- The OP is directed to pay balance amount of Rs. 3,49,884/- (Rupees three lacs forty nine thousand eight hundred eighty four) along with compensation in the form of simple interest at the rate of 5 percent per annum from the date of filing consumer complaint (i.e. 11.01.2019) till full realization;
- The OP is directed to pay Rs. 5,000/- (Rupees five thousand) to the complainant as costs of litigation;
- The above payment must be paid within 45 days from the date of this order in default, complainant shall be at liberty to take recourse to execution proceedings under the provision of Consumer Protection Act.
A copy of this order as per statutory requirements be sent to the parties free of charge.
